Combined orbital irradiation and systemic steroids compared with systemic steroids alone in the management of moderate-to-severe Graves' ophthalmopathy: a preliminary study

OBJECTIVE

To assess the efficacy and safety of combined orbital irradiation and systemic steroids in the management of moderate-to-severe Graves' ophthalmopathy.

DESIGN

Single-blind randomised prospective study.

SETTING

Regional hospital, Hong Kong.

PATIENTS

Sixteen patients with active moderate-to-severe Graves' ophthalmopathy who were randomly assigned to steroid therapy (ST group) or combination therapy of orbital irradiation and systemic steroids (SRT group) between June 2000 and June 2003.

MAIN OUTCOME MEASURES

NOSPECS scoring system, total eye score, subjective eye score, and extra-ocular muscle thickness as determined by either computed tomographic or magnetic resonance imaging scans.

RESULTS

The study was completed by 15 of 16 patients. Both groups experienced improvement in total eye score, soft tissue swelling, ocular motility, visual acuity, and subjective eye score at 52-week follow-up. Total eye score improved earlier in the SRT group, achieving statistical significance (P<0.05) at as early as 4 weeks of follow-up. Improvement in ocular parameters was greater and led to a significantly greater reduction in total eye score than in the ST group at weeks 16, 24, and 52. Maximum extra-ocular muscle thickness was significantly reduced in the SRT group only. No change was observed in proptosis in either group. No serious adverse effect was observed with the addition of orbital irradiation to steroid therapy.

CONCLUSION

A combination of orbital irradiation and systemic steroids is well tolerated and more effective than steroids alone in the treatment of active moderate-to-severe Graves' ophthalmopathy. It achieves greater and more rapid improvement in soft tissue swelling, ocular motility, and visual acuity.

Overall Survival After Concurrent Cisplatin-Radiotherapy Compared With Radiotherapy Alone in Locoregionally Advanced Nasopharyngeal Carcinoma

This phase III randomized study compared concurrent cisplatin-radiotherapy (CRT) versus radiotherapy (RT) alone in patients with locoregionally advanced nasopharyngeal carcinoma. A total of 350 patients were randomly assigned to receive external RT alone or concurrently with cisplatin at a dosage of 40 mg/m(2) weekly. The primary endpoint was overall survival, and the median follow-up was 5.5 years. The 5-year overall survival was 58.6% (95% confidence interval [CI] = 50.9% to 66.2%) for the RT arm and 70.3% (95% CI = 63.4% to 77.3%) for the CRT arm. In Cox regression analysis adjusted for T stage, age, and overall stage, the difference in overall survival was statistically significantly in favor of concurrent CRT (P = .049, hazard ratio [HR] = 0.71 [95% CI = 0.5 to 1.0]). Subgroup analysis demonstrated that there was no difference between overall survival in the arms for T1/T2 stage (P = .74, HR = 0.93 [95% CI = 0.59 to 1.4]), whereas there was a difference between the arms for T3/T4 stage (P = .013, HR = 0.51 [95% CI = 0.3 to 0.88]), favoring the CRT arm. The regimen of weekly concurrent CRT is a promising standard treatment strategy for locoregionally advanced nasopharyngeal carcinoma patients.

Changes in Clinical Presentation, Management and Outcome in 1348 Patients with Differentiated Thyroid Carcinoma: Experience in a Single Institute in Hong Kong, 1960–2000

The clinical features, management and outcome of 1348 patients diagnosed with differentiated thyroid carcinoma in Queen Elizabeth Hospital, Hong Kong, were analysed according to the period of diagnosis: A (before 1980), B (1981-1990) and C (1991-2000). As time advanced, ratio of papillary carcinoma (PTC) to follicular carcinoma (FTC) increased (A:B:C = 1.6: 3.1: 7.2). The mean size of the primary tumour decreased (A:B:C = 3.5 cm: 2.8 cm: 2.5 cm), with a greater percentage of microcarcinoma of 1 cm or less (A:B:C = 5.1%: 16.1%: 21.7%). At presentation, the incidence of lymph-node metastasis decreased (A:B:C = 32.7%: 31.6%: 24.8%) and that of distant metastasis decreased (A:B:C = 9%: 6.1%: 5.3%). Bilateral surgical resection was more commonly used (A:B:C = 62.8%: 89.1%: 94.8%) than lobectomy (A:B:C = 26.3%: 2.8%: 1.8%). Radiation treatment, radioactive iodine (131I; RAI) and external radiotherapy (EXT), was more commonly used (A:B:C = 53.2%: 74.7%: 85.1%). RAI was used in 84.3% (A:B:C = 50%: 71.2%: 84.3%) and EXT in 14.5% of patients in the past decade (A:B:C = 10.9%: 8.7%: 14.5%). The proportion of patients who adopted a bilateral surgery and RAI treatment increased gradually with time (A:B:C = 33%: 68%: 83.8%). The 5-year cause-specific survival (A:B:C = 90.2%: 93.7%: 95.7%), locoregional failure-free survival (A:B:C = 72.6%: 82.9%: 91.6%) and distant metastasis failure-free survival (A:B:C = 84.5%: 89.1%: 92.6%) were improved. However, the period of diagnosis was not found to be an important explanatory variable (i.e. P > 0.05) in Cox regression after adjusting for other factors, indicating that the improvement was probably related to the temporal trend of other factors: presentation at earlier stage, increased ratio of PTC:FTC and more aggressive management by bilateral surgery and radiation therapy.

Concurrent chemotherapy-radiotherapy compared with radiotherapy alone in locoregionally advanced nasopharyngeal carcinoma: progression-free survival analysis of a phase III randomized trial

PURPOSE

Nasopharyngeal carcinoma (NPC) is highly sensitive to both radiotherapy (RT) and chemotherapy. This randomized phase III trial compared concurrent cisplatin-RT (CRT) with RT alone in patients with locoregionally advanced NPC.

PATIENTS AND METHODS

Patients with Ho's N2 or N3 stage or N1 stage with nodal size > or = 4 cm were randomized to receive cisplatin 40 mg/m(2) weekly up to 8 weeks concurrently with radical RT (CRT) or RT alone. The primary end point was progression-free survival (PFS).

RESULTS

Three hundred fifty eligible patients were randomized. Baseline patient characteristics were comparable in both arms. There were significantly more toxicities, including mucositis, myelosuppression, and weight loss in the CRT arm. There were no treatment-related deaths in the CRT arm, and one patient died during treatment in the RT-alone arm. At a median follow-up of 2.71 years, the 2-year PFS was 76% in the CRT arm and 69% in the RT-alone arm (P =.10) with a hazards ratio of 1.367 (95% confidence interval [CI], 0.93 to 2.00). The treatment effect had a significant covariate interaction with tumor stage, and a subgroup analysis demonstrated a highly significant difference in favor of the CRT arm in Ho's stage T3 (P =.0075) with a hazards ratio of 2.328 (95% CI, 1.26 to 4.28). For T3 stage, the time to first distant failure was statistically significantly different in favor of the CRT arm (P =.016).

CONCLUSION

Concurrent CRT is well tolerated in patients with advanced NPC in endemic areas. Although PFS was not significantly different between the concurrent CRT arm and the RT-alone arm in the overall comparison, PFS was significantly prolonged in patients with advanced tumor and node stages.

Fine needle aspiration diagnosis of angiomyolipoma of the liver using a cell block with immunohistochemical study. A case report

Fine needle aspiration diagnosis of hepatic angiomyolipoma has been reported rarely. Below we report one such case diagnosed by examination of a cell block. The presence of epithelioid smooth muscle cells, mature adipocytes, thick-walled vessels and extramedullary hematopoiesis established the diagnosis. It was further substantiated by positive staining of the epithelioid cells for muscle-specific actin (HHF-35). The epithelioid cells were also immunoreactive with a melanocytic marker, HMB-45, but not with desmin, vimentin, cytokeratin or S-100 protein. HMB-45 might prove to be a sensitive marker for the epithelioid smooth muscle component of the tumor. The advantage of the routine use of a cell block in fine needle aspiration is emphasized.